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A New Policy Brief from PEPReC: Telehealth Use and Availability in VHA Outpatient Mental Health Care

Introduction

VA has expanded telehealth services significantly since the start of the COVID-19 pandemic, increasing Veterans’ access to care. Despite notable increases in telehealth use and availability, in-person care remains prevalent for mental health care (MH) services. A new policy brief from the QUERI-funded Partnered Evidence-based Policy Resource Center (PEPReC)—which collaborates with operational partners to design and execute randomized evaluations of VHA initiatives, develops and refines performance metrics, and writes evidence-based policy briefs—indicates that continuing to provide MH virtually and in person will likely be the best Veteran-centered approach to access.

Telehealth, also known as virtual care, uses information and communication technology to provide health care services to Veterans outside of traditional in-person settings. VA telehealth services include video care (such as VA Video Connect), phone consultations, and digital tools to navigate health care (such as the My HealtheVet online portal and VA mobile apps). While not always an appropriate alternative to in-person care, telehealth offers increased flexibility and advantages for Veterans and providers, such as reduced travel time and risk of spreading disease. Telehealth can also help alleviate provider shortages by allowing providers to serve Veterans outside of their typical service areas.

After the onset of the COVID-19 pandemic, in June 2020, telehealth in VA grew dramatically, with 58% of care provided via telehealth, compared to 14% prior to March 2020. ^[1] Among VA health care specialties, mental health telehealth use grew the most during the pandemic.

PEPReC’s Findings

To explore the extent to which in-person visits might have been substituted with telehealth over time, PEPReC examined the volume of three health care modalities: in person, phone, and video. Investigators reviewed the use of each modality across medical centers, providers, and Veterans.

• Prior to the COVID-19 pandemic, telehealth represented 3% of all MH visits (1% video and 2% phone). With the pandemic’s onset, phone visits grew to about 57% in 2020 Q2, then decreased substantially to about 10% by 2022 Q4. As the number of phone visits decreased, video care increased, representing 52% of MH visits by 2022 Q4. By early 2023, 36% of Veterans scheduled exclusively in person and 56% opted solely for telehealth visits.
• Since 2020, more MH providers have offered a mix of care modalities. By 2022, 98% of all VA MH providers conducted both telehealth and in-person MH visits. At the start of the pandemic, 70% of individual providers were almost exclusively providing telehealth. However, this share decreased to 30% by 2023 Q1. Despite having multiple modalities available, most Veterans use only one.
• In 2022, most Veterans exclusively used telehealth for outpatient MH appointments. Veterans living in rural areas seemed to choose exclusively in-person care slightly more often than Veterans in urban areas (30% rural vs. 27% urban).

Policy Implications

Despite the rapid rise in telehealth use for outpatient MH, not all Veterans and providers have adopted it to the same extent, and PEPReC observations suggest that one care modality might not suit all Veteran needs. Policymakers should also consider the following:

• There might be logistical challenges to using telehealth for certain populations, such as older adults in rural areas who might struggle with technology or internet access.
• Telehealth has the potential to address disparities for marginalized groups (e.g., rural, elderly, people with serious mental illness, people of color, Veterans of low socioeconomic status) and improve access to care.
• Policymakers might want to offer Veterans a choice in care modality for MH care services.
• PEPReC’s findings focus on services provided by social workers, psychologists, and psychiatrists, which can include therapy, medication management, care coordination, and peer support groups. Other MH diagnostic services and treatments might still require in-person visits.
• Telehealth might increase access to urgent MH care such as suicide prevention and crisis interventions. Further evaluation is needed to determine telehealth’s impact on Veteran health outcomes and access in urgent MH care.

Download Telehealth Use and Availability in VHA Outpatient Mental Health Care.

Contributors to the PEPReC report are part of the VA Boston Health Care System: PhiYen Nguyen, MPP, Policy Analyst
Izabela Sadej, MSW, Senior Policy Analyst
Elsa Pearson Sites, MPH, Policy Director
Jessica Lum, MA, Senior Data Analyst
Christine Yee, PhD, Investigator
Steven Pizer, PhD, Chief Economist

^[1] Ferguson JM, Jacobs J, Yefimova M, et al. Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization. Journal of the American Medical Informatics Association: JAMIA. 2021; 28(3), 453–462.